<!--<include file="Core_Extend::template('header')" />-->

<!--{:Core_Extend::validate()}-->

<!--{script}-->
checkForm();
<!--{/script}-->

	<div class="container_12">
		<ul class="breadcrumb">
			<li><a href="<!--{:__APP__}-->" title="<!--<lang package='__COMMON_LANG__@Common'>-->主页<!--</lang>-->"><!--<lang package='__COMMON_LANG__@Common'>-->主页<!--</lang>--></a>&nbsp;<span class="divider">/</span>&nbsp;</li>
			<li><!--<lang package='Template'>-->填写联系方式<!--</lang>--></li>
		</ul>
	</div>

	<div class="container_12 container_box">
		<!--<include file="userappeal+menu" />-->
		
		<div class="grid_12">
			<form class="form-horizontal validate" method='post' name="userappeal2_form" id="userappeal2_form" action="<!--{:Q::U('home://userappeal/step3')}-->">
				<fieldset>
					<div class="tips"><h3><!--<lang package='Template'>-->申诉基本资料<!--</lang>--></h3></div>
					<div class="control-group">
						<label class="control-label" for="real_name"><!--<lang package='Template'>-->您的真实姓名<!--</lang>--><em class="red">*</em></label>
						<div class="controls">
							<input class="input-xlarge {required:true}" id="real_name" name="real_name" type="text" value="" required>
							<p class="input_errortips"></p>
						</div>
					</div>
					<div class="control-group">
						<label class="control-label" for="address"><!--<lang package='Template'>-->您的详细地址<!--</lang>--></label>
						<div class="controls">
							<input class="input-xlarge {required:true}" id="address" name="address" type="text" value="" required>
							<p class="input_errortips"></p>
						</div>
					</div>
					<div class="control-group">
						<label class="control-label" for="id_number"><!--<lang package='Template'>-->您的身份证号码<!--</lang>--></label>
						<div class="controls">
							<input class="input-xlarge {required:ture,isIdCardNo:true}" id="id_number" name="id_number" type="text" value="">
							<p class="input_errortips"></p>
						</div>
					</div>
					<div class="tips"><h3><!--<lang package='Template'>-->申诉结果接收方式<!--</lang>--></h3></div>
					<div class="control-group">
						<label class="control-label" for="appeal_email"><!--<lang package='Template'>-->接收申诉结果的邮箱<!--</lang>--><em class="red">*</em></label>
						<div class="controls">
							<input class="input-xlarge {required:true,email:ture}" id="appeal_email" name="appeal_email" type="text" value="">
							 <p class="input_tips"><!--<lang package='Template'>-->申诉成功后，该邮箱会自动设置为个人资料中的联系邮箱<!--</lang>--></p>
							 <p class="input_errortips"></p>
						</div>
					</div>
					<div class="control-group">
						<label class="control-label" for="seccode"><!--<lang package='__COMMON_LANG__@Common'>-->验证码<!--</lang>--></label>
						<div class="controls">
							<input name="seccode" id="seccode" type="text" class="input-small {required:true,remote:Q.U('home://public/validate_seccode'),messages:{remote:'<!--<lang package='__COMMON_LANG__@Common'>-->验证码错误<!--</lang>-->'}} left" value="">&nbsp;
							<span class="validate_seccode"><span class="input_errortips"></span></span>
							<p class="help-block" style="clear:both;padding-top:10px;"><span id="seccodeImage"><img style="cursor:pointer" onclick="updateSeccode()" src="<!--{:Q::U('home://public/seccode')}-->" /></span></p>
						</div>
					</div>
					<div class="form-actions">
					<input type="hidden" value="<!--{$sUserid}-->" name="user_id"/>
						<button type="submit" class="btn"><!--<lang package='__COMMON_LANG__@Common'>-->提交<!--</lang>--></button>
					</div>
				</fieldset>
			</form>
		</div>
	</div>

<!--<include file="Core_Extend::template('footer')" />-->